Download as pdf or txt
Download as pdf or txt
You are on page 1of 54

Pediatric Orthopedics Symptoms

Differential Diagnosis Supplementary


Assessment and Treatment 1st Edition
Jan Douwes Visser
Visit to download the full and correct content document:
https://textbookfull.com/product/pediatric-orthopedics-symptoms-differential-diagnosis
-supplementary-assessment-and-treatment-1st-edition-jan-douwes-visser/
More products digital (pdf, epub, mobi) instant
download maybe you interests ...

Community Pharmacy: Symptoms, Diagnosis and Treatment


Paul Rutter

https://textbookfull.com/product/community-pharmacy-symptoms-
diagnosis-and-treatment-paul-rutter/

Neuropsychological Tools for Dementia: Differential


Diagnosis and Treatment 1st Edition Helmut Hildebrandt

https://textbookfull.com/product/neuropsychological-tools-for-
dementia-differential-diagnosis-and-treatment-1st-edition-helmut-
hildebrandt/

Pediatric Trauma: Pathophysiology, Diagnosis, and


Treatment, Second Edition David E. Wesson

https://textbookfull.com/product/pediatric-trauma-
pathophysiology-diagnosis-and-treatment-second-edition-david-e-
wesson/

Functional Somatic Symptoms in Children and


Adolescents: A Stress-System Approach to Assessment and
Treatment Kasia Kozlowska

https://textbookfull.com/product/functional-somatic-symptoms-in-
children-and-adolescents-a-stress-system-approach-to-assessment-
and-treatment-kasia-kozlowska/
Anal Fissure Symptoms Diagnosis and Therapies 1st
Edition Volker Wienert

https://textbookfull.com/product/anal-fissure-symptoms-diagnosis-
and-therapies-1st-edition-volker-wienert/

ADHD: A Guide to Understanding Symptoms, Causes,


Diagnosis, Treatment, and Changes Over Time in
Children, Adolescents, and Adults Fifth Edition Paul H.
Wender
https://textbookfull.com/product/adhd-a-guide-to-understanding-
symptoms-causes-diagnosis-treatment-and-changes-over-time-in-
children-adolescents-and-adults-fifth-edition-paul-h-wender/

Oral Pathology in the Pediatric Patient A Clinical


Guide to the Diagnosis and Treatment of Mucosal Lesions
1st Edition Elizabeth Philipone

https://textbookfull.com/product/oral-pathology-in-the-pediatric-
patient-a-clinical-guide-to-the-diagnosis-and-treatment-of-
mucosal-lesions-1st-edition-elizabeth-philipone/

Pediatric Orthopedics and Sports Medicine: A Handbook


for Primary Care Physicians 2nd Edition Amr Abdelgawad

https://textbookfull.com/product/pediatric-orthopedics-and-
sports-medicine-a-handbook-for-primary-care-physicians-2nd-
edition-amr-abdelgawad/

Acanthamoeba Keratitis Diagnosis and Treatment 1st


Edition Xuguang Sun (Auth.)

https://textbookfull.com/product/acanthamoeba-keratitis-
diagnosis-and-treatment-1st-edition-xuguang-sun-auth/
Jan Douwes Visser

Pediatric
Orthopedics
Symptoms, Differential
Diagnosis, Supplementary
Assessment and Treatment

123
Pediatric Orthopedics
Jan Douwes Visser

Pediatric Orthopedics
Symptoms, Differential Diagnosis,
Supplementary Assessment
and Treatment
Jan Douwes Visser
Groningen
The Netherlands

Word processing: Hendrika Schotanus and Yvonne Werink. Translation: Prof. Peter
H. Robinson, MD., Ph.D. Drawings: Douwe Buiter

ISBN 978-3-319-40176-8    ISBN 978-3-319-40178-2 (eBook)


DOI 10.1007/978-3-319-40178-2

Library of Congress Control Number: 2016960534

© Springer International Publishing 2017


This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or
part of the material is concerned, specifically the rights of translation, reprinting, reuse of
illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way,
and transmission or information storage and retrieval, electronic adaptation, computer software,
or by similar or dissimilar methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this
publication does not imply, even in the absence of a specific statement, that such names are
exempt from the relevant protective laws and regulations and therefore free for general use.
The publisher, the authors and the editors are safe to assume that the advice and information in
this book are believed to be true and accurate at the date of publication. Neither the publisher nor
the authors or the editors give a warranty, express or implied, with respect to the material
contained herein or for any errors or omissions that may have been made. The publisher remains
neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Printed on acid-free paper

This Springer imprint is published by Springer Nature


The registered company is Springer International Publishing AG
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
Preface

In practice, we do not tend to think in terms of differential diagnosis. We


often consider the most probable diagnosis based on the patient’s complaints.
Only when the most probable diagnosis is not supported by physical exami-
nation and/or supplementary tests, do we further consider the other possibili-
ties. In this book, Pediatric Orthopedics: Symptoms, Differential Diagnosis,
Supplementary Assessment and Treatment, we are working towards a system
for differential diagnosis based on the principal complaints and findings.
In some cases there are more than one different kinds of complaint. As an
example, in Osgood-Schlatter, there are complaints of pain and swelling. In
those cases we consider the most preveland complaint which in Osgood-
Schlatter is pain. In other cases, for instance a meniscal tear, there may be
several individual complaints or a combination of these such as pain medially
or laterally combined with limited extension and/or swelling. A torn menis-
cus appears in several differential diagnoses. A system has been established
for every diagnosis as described here: (a) explanatory notes, (b) advice on
supplementary tests, (c) advice as to which problems can be treated in pri-
mary care, (d) when to refer for secondary care treatment, and (e) what the
options are for secondary care treatment. Generalized neurological disorders
and neuromuscular disorders such as in spasticity, spina bifida, and acute
traumatic lesions have been left out. There are many diverse treatment pos-
sibilities available. However, many pediatric orthopedic treatments are not
evidence based or sometimes have a low or extremely low value from the
literature. The author, advisers, and the publisher are not responsible for
faults, omissions, or other implications as a result of the information given in
this book. Application of the information given in this publication remains
the responsibility of the clinician involved.

Groningen, The Netherlands Jan Douwes Visser

v
Acknowledgments

Advisory Board
Minne Heeg, M.D., Ph.D.
Pediatric orthopedic surgeon
Wilhelmina Hospital Assen, The Netherlands
Sjoerd K. Bulstra, M.D., Ph.D.
Professor and chairman Department of Orthopedic Surgery
University Medical Center Groningen, The Netherlands
Peter H. Robinson, M.D., Ph.D.
Emeritus Professor of Plastic, Hand and Reconstructive Surgery
University Medical Center Groningen, The Netherlands

vii
Abbreviations

ANF Antinuclear factor


C Cervical
CRP C-reactive protein
CT Computed tomography
ESR Erythrocyte sedimentation rate
Hb Hemoglobin
HLA Human leukocyte antigen
Ht Hematocrit
L Lumbar
MRA Magnetic resonance arthrography
MRI Magnetic resonance imaging
n. Nerve
NSAID Non-steroidal anti-inflammatory drugs
S Sacral
T Thoracal
WBC count White blood cell count

ix
Contents

1 Chest Wall��������������������������������������������������������������������������������������    1


Chest Wall Deformity����������������������������������������������������������������������    1
Chest Wall Pain��������������������������������������������������������������������������������    3
2 Neck������������������������������������������������������������������������������������������������    7
Neck Deformity ������������������������������������������������������������������������������    7
Neck Flexion Deformity��������������������������������������������������������������    7
Short Neck ����������������������������������������������������������������������������������    7
Wry Neck ������������������������������������������������������������������������������������    9
Neck Pain ����������������������������������������������������������������������������������������   12
Acute Onset of a Painful Stiff and Possibly Wry Neck ��������������   12
Slow Onset Painful Stiff and Possibly Wry Neck������������������������   16
Painful Stiff and Possibly Wry Neck with Neurological
Symptoms������������������������������������������������������������������������������������   17
3 Back������������������������������������������������������������������������������������������������   21
Back Misalignment��������������������������������������������������������������������������   21
Lateral Curvature(s) of the Back��������������������������������������������������   21
Abnormal Rounded Back������������������������������������������������������������   34
Abnormal Hollow Back ��������������������������������������������������������������   41
Combined Curvatures������������������������������������������������������������������   45
Back Pain ����������������������������������������������������������������������������������������   45
Back Pain ������������������������������������������������������������������������������������   45
Back Pain Accompanied by Noctural Sweating��������������������������   51
Back Pain with Neurological Symptoms ������������������������������������   52
4 Pelvis������������������������������������������������������������������������������������������������   57
Pelvic Pain ��������������������������������������������������������������������������������������   57
5 Shoulder������������������������������������������������������������������������������������������   61
Shoulder Anomalies ������������������������������������������������������������������������   61
Absent Collarbone ����������������������������������������������������������������������   61
Elevated Shoulder Blade��������������������������������������������������������������   61
Repeated Non Traumatic Shoulder Subluxation/
Dislocation ����������������������������������������������������������������������������������   64
Repeated Traumatic Shoulder Subluxation/Dislocation��������������   66

xi
xii Contents

Shoulder Swelling����������������������������������������������������������������������������   69


Collarbone Swelling in Newborns ����������������������������������������������   69
Swelling of the Shoulder Blade or Collarbone
or Upper Arm ������������������������������������������������������������������������������   70
Shoulder Movement Limitations in Newborns��������������������������������   71
Paralysis of the Arm at Birth��������������������������������������������������������   71
Shoulder Pain ����������������������������������������������������������������������������������   74
Vague Shoulder Pain��������������������������������������������������������������������   74
Shoulder Pain After a Trivial Trauma������������������������������������������   75
Shoulder Pain in Overhead Athletes��������������������������������������������   76
Painful Shoulder Movement Trajectory ��������������������������������������   76
Extremely Painful Immobile Shoulder����������������������������������������   77
6 Elbow and Forearm ����������������������������������������������������������������������   79
Elbow Misalignment������������������������������������������������������������������������   79
Crooked Elbow After a Fracture��������������������������������������������������   79
Repeated Elbow Subluxation/Dislocation ����������������������������������   80
Elbow Swelling��������������������������������������������������������������������������������   81
Elbow Swelling on the Back or Front or Outer Side ������������������   81
Elbow and Forearm Movement Limitations������������������������������������   82
Limited Extension and/or Flexion in the Elbow
After a Fracture����������������������������������������������������������������������������   82
Forearm Movement Limitation����������������������������������������������������   83
Elbow Pain ��������������������������������������������������������������������������������������   84
Pain in the Outer Side of the Elbow After Arm Traction ������������   84
Pain in the Outer Side of the Elbow��������������������������������������������   86
Pain in the Inner Side of the Elbow ��������������������������������������������   87
Extremely Painful Immobile Elbow��������������������������������������������   87
7 Wrist������������������������������������������������������������������������������������������������   91
Wrist Misalignment ������������������������������������������������������������������������   91
Crooked Wrist������������������������������������������������������������������������������   91
Wrist Swelling ��������������������������������������������������������������������������������   92
Hard Swelling on the Back of the Wrist��������������������������������������   92
Soft Swelling on the Back or Front of the Wrist��������������������������   93
Wrist Pain����������������������������������������������������������������������������������������   94
Pain on the Back of the Wrist������������������������������������������������������   94
Wrist Pain After a Trauma ����������������������������������������������������������   95
Severely Painful Immobile Wrist������������������������������������������������   96
8 Hand������������������������������������������������������������������������������������������������   99
Thumb and Finger Abnormalities����������������������������������������������������   99
Extra Thumb or Finger(s)������������������������������������������������������������   99
Gigant Growth of Thumb and/or Finger(s)���������������������������������� 102
Finger Misalignment�������������������������������������������������������������������� 104
Short Finger �������������������������������������������������������������������������������� 106
Fused Fingers and/or Thumb ������������������������������������������������������ 106
Thumb Misalignment������������������������������������������������������������������ 107
Long Thumb�������������������������������������������������������������������������������� 110
Short Thumb�������������������������������������������������������������������������������� 111
Hand Swelling���������������������������������������������������������������������������������� 114
Contents xiii

9 Hip �������������������������������������������������������������������������������������������������� 117


Hip Movement Limitations in Babies and Infants �������������������������� 117
Hip Movement Limitation Away from
the Midline of the Body �������������������������������������������������������������� 117
The Legs Can Not Be Approximated
or with Pelvic Obliquity�������������������������������������������������������������� 140
Waddling Gait���������������������������������������������������������������������������������� 141
Snapping Hip ���������������������������������������������������������������������������������� 143
Hip Pain ������������������������������������������������������������������������������������������ 146
Vague Pain Around Groin or Pelvis or Upper Leg���������������������� 146
Hip Pain and Limited Internal Rotation�������������������������������������� 147
Hip Pain and Movement Limitation in All Directions ���������������� 163
Hip Pain After a Trivial Trauma������������������������������������������������������ 165
Extremely Painful Immobile Hip������������������������������������������������ 167
10 Knee������������������������������������������������������������������������������������������������ 171
Knee Misalignment�������������������������������������������������������������������������� 171
Bowleg ���������������������������������������������������������������������������������������� 171
Knock Knee �������������������������������������������������������������������������������� 179
Overstretched Knee Deformity���������������������������������������������������� 186
Bent Knee Deformity������������������������������������������������������������������ 192
Repeated Kneecap Subluxation/Dislocation�������������������������������� 193
Knee Swelling���������������������������������������������������������������������������������� 198
Swelling Just Above and/or Below the Knee������������������������������ 198
Swelling at the Back of the Knee������������������������������������������������ 199
Knee Movement Limitations ���������������������������������������������������������� 200
Knee Stretch Limitation�������������������������������������������������������������� 200
Knee Bending Limitation������������������������������������������������������������ 206
Knee Effusion���������������������������������������������������������������������������������� 206
Knee Effusion Within a Few Hours After Trauma���������������������� 206
Knee Effusion Within 24 h After Trauma������������������������������������ 215
Knee Effusion Without a Preceding Trauma�������������������������������� 216
Knee Effusion Skipping to Other Joints�������������������������������������� 220
Knee Effusion Accompanied by Nocturnal Sweating������������������ 221
Knee Pain ���������������������������������������������������������������������������������������� 223
Vague Pain Just Above or Below the Knee���������������������������������� 223
Pain in the Inner or Outer Side of the Knee�������������������������������� 229
Pain at the Front of the Knee ������������������������������������������������������ 229
Thigh and Knee Pain�������������������������������������������������������������������� 234
Extremely Painful Immobile Knee���������������������������������������������� 235
11 Lower Leg �������������������������������������������������������������������������������������� 237
Lower Leg Misalignment���������������������������������������������������������������� 237
Forwards and Outwards Lower Leg Bowing ������������������������������ 237
Backwards and Inwards Lower Leg Bowing ������������������������������ 240
Lower Leg Pain�������������������������������������������������������������������������������� 243
Severe Lower Leg Pain���������������������������������������������������������������� 243
Pain in the Outer Side of the Lower Leg�������������������������������������� 244
Pain in the Inner Side of the Lower Leg�������������������������������������� 246
xiv Contents

12 Ankle ���������������������������������������������������������������������������������������������� 249


Ankle Misalignment������������������������������������������������������������������������ 249
The Heel Progressively Deviates Outwards
(Valgus Deformity)���������������������������������������������������������������������� 249
The Heel Progressively Deviates Inwards
(Varus Deformity)������������������������������������������������������������������������ 252
Ankle Pain���������������������������������������������������������������������������������������� 253
Pain at the Front of the Ankle������������������������������������������������������ 253
Pain at the Back of the Ankle������������������������������������������������������ 255
Extremely Painful Immobile Ankle �������������������������������������������� 256
Ankle Sprain������������������������������������������������������������������������������������ 256
13 Foot�������������������������������������������������������������������������������������������������� 261
Foot Deformities������������������������������������������������������������������������������ 261
Foot Deformities Present at Birth������������������������������������������������ 261
Toe Walking �������������������������������������������������������������������������������� 276
Flattened Longitudinal Medial Foot Arch������������������������������������ 279
Abnormal High Longitudinal Medial Foot Arch ������������������������ 285
Foot Pain������������������������������������������������������������������������������������������ 291
Pain in the Outer Side of the Hindfoot���������������������������������������� 291
Heel Pain�������������������������������������������������������������������������������������� 292
Pain in the Inner Side of the Midfoot������������������������������������������ 294
Painful Swelling on the Upper Outer Side of the Heel���������������� 295
Painful Swelling on the Inner Side of the Midfoot���������������������� 295
Painless Bilateral Swelling on the Medial
Side of the Footsole �������������������������������������������������������������������� 296
14 Toes�������������������������������������������������������������������������������������������������� 299
Abnormal Toe���������������������������������������������������������������������������������� 299
Extra Toe�������������������������������������������������������������������������������������� 299
Giant Toe Growth������������������������������������������������������������������������ 300
Bent Toe Deformity �������������������������������������������������������������������� 301
Overlapping Toe�������������������������������������������������������������������������� 303
Short Toes������������������������������������������������������������������������������������ 304
Fused Toes������������������������������������������������������������������������������������ 304
The Big Toe Deviates Medially �������������������������������������������������� 306
The Big Toe Deviates Laterally �������������������������������������������������� 306
The Little Toe Is Deviated Medially�������������������������������������������� 312
Painful Toes�������������������������������������������������������������������������������������� 314
Painful Stiff Big Toe�������������������������������������������������������������������� 314
Pain at the Level of the Head of the Second
Metatarsal (or Third or Fourth or Fifth)�������������������������������������� 315
Toenail Pain���������������������������������������������������������������������������������� 315
15 Leg Length Inequality ������������������������������������������������������������������ 319
One Leg is Shorter or Longer than the Other���������������������������������� 319
One Leg is Shorter than the Other ���������������������������������������������� 319
One Leg is Longer than the Other������������������������������������������������ 324
Contents xv

16 Abnormal Gait ������������������������������������������������������������������������������ 333


Introduction�������������������������������������������������������������������������������������� 333
Gait Disorders���������������������������������������������������������������������������������� 333
Limping���������������������������������������������������������������������������������������� 333
Waddling Gait������������������������������������������������������������������������������ 333
Toe Walking �������������������������������������������������������������������������������� 337
Out-Toeing ���������������������������������������������������������������������������������� 337
Intoeing���������������������������������������������������������������������������������������� 338
Unburdening Hip Gait������������������������������������������������������������������ 344
Gaits with a Shortened Standing Phase �������������������������������������� 345
17 Limb and Back Reduction Deficiency Present at Birth������������� 347
Limb General ���������������������������������������������������������������������������������� 347
Classification�������������������������������������������������������������������������������� 347
Frequency������������������������������������������������������������������������������������ 349
Upper Limb�������������������������������������������������������������������������������������� 349
Absence of the Whole or Part of the Arm������������������������������������ 349
Absence of the Whole Arm or Upper Arm or Forearm
Between the Trunk and the Hand in Which Case
the Elbow Joint Is Always Absent������������������������������������������������ 354
Abnormal Forearm and/or Hand�������������������������������������������������� 355
Lower Limb������������������������������������������������������������������������������������� 365
Absence of the Whole or Part of the Leg������������������������������������ 365
Absence of the Whole Leg or Thigh or Lower Leg
Between the Trunk and the Foot, in Which Case
the Knee Joint Is Always Absent������������������������������������������������� 366
Short Upper Leg, the Knee Joint Is Always Present�������������������� 368
Abnormal Lower Leg and/or Foot ���������������������������������������������� 376
Back ������������������������������������������������������������������������������������������������ 389
Buddhist Posture�������������������������������������������������������������������������� 389
18 Bone and Joint Infections�������������������������������������������������������������� 393
Extremely Painful Immobile Extremity������������������������������������������ 393
Incidence�������������������������������������������������������������������������������������� 394
Pathogenesis of Acute Osteomyelitis������������������������������������������ 394
Pathogenesis of Septic Arthritis �������������������������������������������������� 395
Localization���������������������������������������������������������������������������������� 396
More Locations���������������������������������������������������������������������������� 396
Pathogens ������������������������������������������������������������������������������������ 397
Late Complications���������������������������������������������������������������������� 400
Caffey Disease ���������������������������������������������������������������������������� 402
Addendum���������������������������������������������������������������������������������������������� 407
Appendix������������������������������������������������������������������������������������������������ 409
Literature������������������������������������������������������������������������������������������������ 425
Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 431
Chest Wall
1

Chest Wall Deformity Fusion disorder of the sternum Partial fusion dis-
orders of the cranial area are the most common. In
 Complaint: there is a deformity of the chest the distal area they are very rare. It is also possible
wall. that the sternum is split along the entire length (total
sternal fissure). This abnormality is accompanied by
Assessment: deformity of the chest wall.
cardiac anomalies and/or defects in the diaphragm.
Differential diagnosis:
pectus carinatum (pigeon breast) Absent ribs In this abnormality several ribs are
pectus excavatum (funnel chest) usually absent on one side of the chest wall.
fusion disorder of the sternum There may also be sternal and vertebral abnor-
absent ribs malities such as hemivertebrae and block verte-
Poland syndrome brae. As a result there is a flail thorax, which can
lead to a shortness of breath.
 Explanatory note: pectus carinatum. The
sternum and the adjoining cartilage and bone
Poland syndrome In Poland syndrome1 there is a
are anteriorly prominent (Fig. 1.1). The abnor-
unilateral absence of the pectoralis minor muscle
mality is most noticeable in the first year of
and the sternal part of the pectoralis major muscle
life, but can also develop during puberty
(Fig. 1.4). Males are affected in 70 % of cases. It is
(Fig. 1.2). As a rule, pigeon breast is only a
generally combined with ­abnormalities of the hand
cosmetic issue. Respiratory difficulties may
on the same side, such as small hands (hypoplasia)
occur when the sternum shifts strongly for-
with absent fingers, webbed fingers (syndactyly)
ward, causing the thorax to be in a continuous
and/or shortened fingers (brachydactyly). The com-
inspiratory position.
bination of hypoplasia of the hand, syndactyly and
brachydactyly is sometimes called symbrachydac-
Pectus excavatum There is an indentation on
tyly. There may also be absence of the forearm flexor
the front side of the chest. The deepest area
muscles and the entire arm may be under-developed.
lies at the level of the distal part of sternum
Associated anomalies may be the Klippel-Feil
and the xiphoid process (Fig. 1.3). The abnor-
syndrome1 (short neck), Möbius syndrome1 (paraly-
mality is usually present at birth, but can also
sis of the facial muscles), a Sprengel deformity
develop later. A funnel chest seldom causes
(elevated shoulder blade) and pectus excavatum.
physical complaints, the issue tends to be only
cosmetic. The abnormality is common in Marfan
syndrome. 1
See Appendix.

© Springer International Publishing 2017 1


J.D. Visser, Pediatric Orthopedics, DOI 10.1007/978-3-319-40178-2_1
2 1 Chest Wall

a b

Fig. 1.1 (a) Boy, about 5 years old, with a pectus carinatum (pigeon breast). (b) After treatment with a trunk orthosis
with a pressure pad

 Supplementary assessment: in a fusion disor-


der of the sternum, cardiac abnormalities or with the help of a trunk orthosis with a pres-
defects in the diaphragm should be ruled out. sure pad at the level of the prominent thoracic
area (Fig. 1.5). A period of 1 year is usually
Primary care treatment: none. sufficient. The intention is to wear the trunk
 When to refer: the child should be referred orthosis day and night, and after correction
as quickly as possible when a shortness of the trunk orthosis should still be worn for
breath accompanies absent ribs. If treat- some time at night. This may also be an
ment of the pigeon breast is desired for effective treatment for some cases when the
cosmetic reasons, it is mostly carried out anomaly develops during puberty. The
starting at the first year of age. Funnel chest assessing physician must be able to manually
treatment is done starting at the age of 6 press the most prominent portion a little pos-
years. Infants with a fusion disorder of the teriorly. If he cannot do that, there is no point
sternum should be referred as quickly as in treating with a trunk orthosis. Treatment
possible. Referral is not indicated for the with a trunk orthosis in adolescents usually
chest deformity in Poland syndrome. has to be continued until full growth has been
achieved. A stiff pectus carinatum may be
Secondary care treatment: pectus carina-
  treated operatively (Fig. 1.6).
tum. Spontaneous resolution of the pigeon
breast may occur before the first year of age. Pectus excavatum Starting at the age of 6 or 7
If the pigeon breast is still present after the years, a pediatric or thoracic surgeon can carry out
first year of age, it can be slowly pushed back a Nuss procedure under thoracoscopic guidance.
Chest Wall Pain 3

Fig. 1.2 A pectus carinatum (pigeon breast) can also Fig. 1.3 Pectus excavatum (funnel chest)
develop during puberty

An incision is made on each side of the chest wall


and a forward-curved bar is inserted which acutely
pushes the indentation forward (Figs. 1.7 and 1.8).
The bar is removed after a few years.

Fusion disorder of the sternum Operative clo-


sure of the defect should be carried out as soon as
possible after birth.

Absent ribs Early operative correction in the


neonatal period gives the best results.

Poland syndrome Treatment of the chest wall


abnormality is not indicated.

Chest Wall Pain

 Complaint: the child complains of pain in


the front side of the chest wall.
Fig. 1.4 Poland syndrome. On the right side there is a
unilateral absence of the pectoralis minor muscle and the  Assessment: there is pain on pulpation at the
sternal portion of the pectoralis major muscle level of the sternum-rib junction.
4 1 Chest Wall

a b

Fig. 1.5 (a) Starting at the first year of age, a pectus carinatum (pigeon breast) can be treated using a trunk orthosis
with a pressure pad for the prominent thoracic area. (b) The pressure pad on the inner side of the trunk orthosis

Fig. 1.6 An extensive


pectus carinatum (pigeon
a b
breast), (a) before and
(b) after operative
correction. There is also a
considerable scoliosis
(Images received from
Prof. D.C. Aronson, M.D.,
Ph.D., The Netherlands)

Differential diagnosis:  Explanatory note: Tietze syndrome. In this


Tietze syndrome syndrome, there is a painful unilateral swell-
costochondritis (costosternal syndrome, ing of the rib cartilage at the level of the
costosternal chondrodynia) costosternal junctions. It usually involves
bone tumor the second or third rib. This is a suspected
Chest Wall Pain 5

Fig. 1.7 Pectus excavatum (funnel


chest): the Nuss operation can be
performed starting at the age of 6
or 7. Under thoracoscopic
guidance, an incision on each side
of the chest wall is made and a
curved metal bar is inserted which
pushes the indentation forwards.
The bar is removed after a few
years

a b

Fig. 1.8 Pectus excava-


tum (funnel chest), (a)
preoperatively. (b) after the
Nuss procedure (Images
received from Prof.
D.C. Aronson, M.D.,
Ph.D., The Netherlands)
6 1 Chest Wall

p­erichondritis with an unknown cause.  When to refer: if a tumor is suspected.


Symptoms tend to disappear spontaneously
 Secondary care treatment: bone tumor. A
after several weeks to months.
bone tumor should be treated in a medical
Costochondritis In contrasts to Tietze syndrome center specialized in bone tumors. Treatment
several costosternal junctions are involved usually depends on the nature of the tumor.
the third, the fourth and the fifth. There is no
swelling. The cause is unknown. Pain from costo- Table 1.1 Tumours at the level of the chest cavity. The
chondritis resolves within a year. tumours identified with the § sign are rare
Benign bone tumors Malignant bone tumors
Bone tumor There is painful swelling at the
Osteochondroma Ewing sarcoma
level of the ribs. It is not possible to manualy press
Enchondroma
the bony swelling posteriorly (see Table 1.1).
Fibrous dysplasia
 Supplementary assessment: If there is any Eosinophilic granuloma
doubt of a tumor X-rays, MRI or CT scan Aneurysmal bone cyst §
may be requested. Osteoid osteoma §
Based on Adler and Kozlowski (1993)
 Primary care treatment: In case of Tietze
syndrome or costochondritis pain medica-
tion may be given if necessary.

Differential Diagnosis Chest Wall Deformity


Prominence of the anterior area of the chest wall. Pectus carinatum (pigeon breast)
Indentation of the anterior area of the chest wall. Pectus excavatum (funnel chest)
Split at the level of the sternum. Fusion disorder of the sternum
Flail thorax. Absent ribs
One-sided absence of the pectoralis minor Poland syndrome
and the sternal part of the pectoralis major muscles.

Diagnosis: Chest Wall Pain


Chest wall pain
Painful swelling of the costosternal junction usually the Tietze syndrome
second or third rib.
Pain without swelling of the costosternal junctions Costochondritis
of the third, fourth and fifth rib.
Painful swelling at the level of the ribs. Bone tumor
Neck
2

Neck Deformity  Secondary care treatment: cervical kypho-


sis. In milder kyphosis without neurological
Neck Flexion Deformity abnormalities a wait-and-see approach may
be taken. One should wait until the age of 18
 Complaint: flexion deformity of the neck. months before performing a spondylodesis
for more severe kyphosis without neurologi-
 
Assessment: instead of a normal cervical
cal abnormalities.
lordosis there is a kyphosis.
Neurological abnormalities necessitate ear-
 Diagnosis: cervical kyphosis lier intervention. In addition to the cervi-
cal spondylodesis, the spinal cord must be
 Explanatory note: cervical kyphosis. A cer-
decompressed.
vical kyphosis in a neutral posture should be
considered abnormal. Cervical kyphosis can
be caused by one or two under- developed Short Neck
vertebral bodies or an operation in which
a laminectomy was performed, or it can be Complaint: short neck.
part of a syndrome (Table 2.1). If it is one
of the symptoms of a syndrome, the child’s  
Assessment: the patient has a short neck
other abnormalities are usually so impres- (Fig. 2.1). In 50 % of cases there is a triad:
sive that the practitioner has not noticed • short neck
the kyphosis in the neck. It is however • limited mobility of the cervical spine
important to identify the cervical kyphosis • growth of cranial hair on the back
because even during infancy compression of
In less than 20 % of cases extra skin can be seen
the spinal cord can already occur, resulting
on the lateral side(s) of the neck with m ­ uscular
in lifelong paraplegia or even death.
­fascial tissue in the form of a wing (pterygium
 Supplementary assessment: anteroposterior colli), known as “webbed neck”. This extra tissue
and lateral X-rays as well as a CT-scan and a
MRI of the cervical spine. Table 2.1 Syndromes with a cervical kyphosis. See
Appendix for features of syndromes
 Primary care treatment: none. Campomelic (camptomelic) dysplasia
 When to refer: all cervical kyphoses should Conradi-Hünermann syndrome
be considered pathological and be referred Larsen syndrome
as quickly as possible. Neurofibromatosis (Von Recklinghausen disease)

© Springer International Publishing 2017 7


J.D. Visser, Pediatric Orthopedics, DOI 10.1007/978-3-319-40178-2_2
8 2 Neck

Fig. 2.1 (a, b) Klippel-


a b
Feil syndrome. The short
neck and the low cranial
hair growth

is spread between the mastoid process and the in adults are possible as a result of compres-
acromion on both sides. sion of the myelum or of the exiting spinal
nerves.
 Diagnosis: Klippel-Feil syndrome1 (con-  Supplementary assessment: X-rays as well
genital brevicollis) as a CT-scan and a MRI of the cervical and
 Explanatory note: Klippel-Feil syndrome. thoracic spines.
The clinical picture was described by the  Primary care treatment: if the patient has no
French physicians Klippel and Feil in 1911 pain or neurological symptoms there will be
as “l’homme sans cou” (man without a neck). a wait-and-see policy. If there is pain, it is
The short neck is caused by vertebrae that advisable to limit the activities and a cervical
have fused together. There may also be a collar can be prescribed.
unilateral unsegmented bony connection,
 
When to refer: in the early phase to the
hemivertebrae, absence of the posterior ele-
pediatrician before detecting any other
ments (arches and spinal processes), a basilar
anomalies. Referral should be made to the
impression, an occipitoatlantal synostosis, an
orthopedic surgeon for additional anomalies
atlanto-­axial subluxation and a hypoplasia of
such as muscular torticollis and scoliosis,
the dens. In 20 % of cases the abnormality is
and to the neurosurgeon if neurological
accompanied by a torticollis, in 60 % there is
complications occur at an older age.
a kyphoscoliosis at the thoracic level caused
by the hemivertebrae and unilateral and Secondary care treatment: Klippel-Feil
 
unsegmented bony connections. In 30 % of syndrome. A torticollis based on a short-
cases there is an elevated posture and under- ened sternocleidomastoid muscle can
development of the shoulder blade, known as be treated by dividing or lengthening
a Sprengel deformity. In about 25 % of cases the muscle. Neurological symptoms are
there are cardiac and renal abnormalities, and caused mostly by an atlantoaxial sublux-
in 30 % deafness. Neurological ­complications ation, a basilar i­mpression or a congenital
occipitoatlantal synostosis (for treatment,
1
See Appendix. see pp. 15, 18, 19).
Neck Deformity 9

Fig. 2.2 (a) Torticollis.


a b
Contracture of the left
sternocleidomastoideus
muscle. An easy way to
determine on which side
the abnormality lies is to
draw an imaginary line
between the pupils. The
shoulder this line points
to is the affected side.
(b) Situation 2 years
after dividing the left
sternocleidomastoid
muscle origin

Wry Neck

 Complaint: a wry neck is usually present at


birth, but sometimes it appears at an older age.
 
Assessment: lateral flexion of the head
towards the affected side, the chin is turned
towards the non-deviated side. An easy way
to determine on which side the deviation lies
is to draw an imaginary line between the
pupils. The shoulder that this line points to is
the affected side (Fig. 2.2).
 Differential diagnosis:
torticollis
infantile muscular torticollis
(congenital ­muscular torticollis)
juvenile muscular torticollis
osseous torticollis
ocular torticollis
 Explanatory note: torticollis. The cause of
the infantile as well as juvenile muscular tor-
ticollis is unknown.
Fig. 2.3 Swelling in the trajectory of the right sternoclei-
Infantile muscular torticollis In 20 % of cases domastoid muscle (arrow)
a swelling in the trajectory of the sternocleido-
mastoid muscle is visible and palpable between appeared. By the age of 4–6 months the ­swelling
10 days and 4 weeks after birth (Fig. 2.3). The has disappeared. In 80 % of cases the swell-
swelling reduces gradually 4 weeks after it has ing is not observed or not recognized, and the
10 2 Neck

a b c

Fig. 2.4 (a) The sternocleidomastoid muscle has a be divided. (b, c): In this case the sternocleidomastoid
sternal and a clavicular origin. The shared muscle belly muscle is divided at the mastoid process and occiput.
inserts into the mastoid process and occiput just behind The origins of the clavicular and sternal head are length-
the ear. The sternocleidomastoid muscle can operatively ened with a Z-plasty (Redrawn from: Ferkel RD, Westin
be lengthened or divided at the level of the clavicle and GW, Dawson EG, Oppenheim WL. Muscular torticollis.
sternum. If there is a recurrence the insertion at the level A modified surgical approach. J Bone Joint Surg Am.
of the mastoid process and occiput may also have to 1983;65-A:894–900)

a­ bnormality is later on identified on the basis of Juvenile muscular torticollis Sometimes a mus-
a contracture of one or both heads of the sterno- cular torticollis appears at childhood. In that case
cleidomastoid muscle. there is a contracture of both heads of the sterno-
The sternocleidomastoid muscle has a sternal cleidomastoid muscle. This condition does not
and a clavicular origin. The joint muscle belly recover spontaneously.
inserts into the mastoid process and occiput just
behind the ear (Fig. 2.4). The cause of the swell- Osseous torticollis Due to the presence of a
ing in the sternocleidomastoid muscle is unclear. hemivertebra (half vertebra) or one or several
It used to be assumed that during a difficult birth asymmetric nonsegmented bony connections, a
(breech presentation or forceps delivery) there wry neck can be present. The patient has Klippel-­
was bleeding into this muscle, followed by fibro- Feil syndrome2 if the neck is also too short.
sis of the hematoma. However, blood in the swell- Goldenhar syndrome or oculoauriculovertebral
ing has never been shown. It is now assumed that dysplasia is a special form of osseous torticol-
the fibrous tissue is already present before birth. lis in which in addition to abnormal vertebrae
there are also eye and ear abnormalities such as
Spontaneous recovery of the torticollis occurs epibulbar dermoid cysts and preauricular skin
during the first year of life in 90 % of cases. If the anomalies.
abnormality persists, the face and the skull will
also become deformed, with a flattening of the Ocular torticollis This anomaly is present from
skull and the face on the side of the contracture birth, but is often only noticed around the age of
(plagiocephaly). A developmental dysplasia of 9 months, after the child has achieved sitting bal-
the hip is found in 20 % of children with an infan- ance. Paresis of the extraocular muscles, gener-
tile muscular torticollis. If there is no contracture ally the superior oblique muscle, causes crossed
of the sternocleidomastoid muscle, the underly- and double vision when the head is held horizon-
ing causes are a congenital anomaly of the skel-
eton or an ocular abnormality. 2
See Appendix.
Neck Deformity 11

Fig. 2.5 (a, b) Neck


a b
orthosis, in this case a
SOMI orthosis (S sternum,
O occiput, M mandibula, I
immobilization)

tally. The child must hold his head slanted in the spontaneous recovery. In such cases, the ster-
frontal plane to prevent double vision. nocleidomastoid muscle should be opera-
tively lengthened or divided at the clavicular
 
Supplementary assessment: radiological
and/or sternal origin (Fig. 2.4). The ideal age
assessment of the cervical spine to reveal or
for operative treatment is in the third year
rule out an osseous torticollis. In infantile
of life. The asymmetry of the face and the
or congenital muscular torticollis an ultra-
skull restores completely after that. Operating
sound of the hips or an anteroposterior
before this age increases the chances of an
X-ray of the pelvis should be made to check
ugly scar and retraction of the skin at the level
for a developmental dysplasia of the hip.
where the sternocleidomastoid muscle has
 Primary care treatment: a patient with infantile been lengthened or divided. Even after this
muscular torticollis is usually referred to a pedi- age it is not too late to carry out the correction.
atric physiotherapist up to the age of 18 months. Good cosmetic results can be achieved up to
The parents do stretching exercises under the the age of 12. The sooner the treatment is
supervision of the pediatric physiotherapist. It implemented, the better the ultimate result
is not certain whether these stretching ­exercises will be with regard to facial symmetry.
influence the natural history. Infantile muscu- Postoperative treatment involves the use
lar torticollis disappears spontaneously around of a neck orthosis day and night for 6 weeks
the first year of life in 90 % of cases. (Fig. 2.5). In the case of a recurrence, in
addition to dividing or lengthening the ori-
 When to refer: children with a muscular or
gin at the level of the clavicle and sternum
osseous torticollis should be referred to an
the insertion at the level of the mastoid pro-
orthopedic surgeon when the child is older
cess should also be divided.
than 18 months. If the sternocleido-mastoid
muscle is not shortened and there are no Juvenile muscular torticollis Usually this type
osseous abnormalities the child should be is permanent and requires operative treatment.
referred to an ophthalmologist.
Osseous torticollis Spondylodesis over a trajec-
 Secondary care treatment: infantile muscu- tory as short as possible should be carried out.
lar torticollis. If the abnormality is still
­present at 1 year of age there is little chance of Ocular torticollis Treatment by an ophthalmologist.
12 2 Neck

Fig. 2.6 Ligaments at the Anterior


level of C1 and C2
Alar ligaments

Insertion of
apical ligament Transverse
of the dens atlantal ligament

Superior articular
surface

Dens of axis
Atlas

Posterior

Neck Pain cases of Down syndrome3. These children


are mostly symptom-free.
 cute Onset of a Painful Stiff
A
and Possibly Wry Neck Atlantoaxial subluxation An anterior atlanto-
axial rotatory displacement can arise as a result
 Complaint: the child has a painful stiff neck of a congenital weakness or tear of the transverse
with a possible abnormal posture. atlantal ligament, which is the case in 10–20 %
of children with Down syndrome. A posterior
 
Assessment: there is no mobility in the atlanto-axial rotatory displacement can occur
cervical spine and there may be a wry as a result of an under-developed (hypoplasia)
neck. or absent (aplasia) dens (Fig. 2.7). Atlantoaxial
 Differential diagnosis: subluxations also appear in dwarfism, such
as spondyloepiphysial dysplasia3 (40 %), often
occipitoatlantal subluxation
accom­panied by hypoplasia of the dens, an os
atlantoaxial subluxation
terminale or an os odontoideum (Fig. 2.8), and
Grisel syndrome
in mucopolysaccharidoses with Morquio syn-
Sandifer syndrome
drome3 as its most common type and is often
spondylodiscitis (discitis)
accompanied by a hypoplasia of the dens.
disc calcification
juvenile idiopathic arthritis
Grisel syndrome Grisel syndrome is character-
 Explanatory note: occipitoatlantal sublux- ized by the acute occurrence of a stiff and wry
ation. An occipitoatlantal subluxation is neck resulting from a throat infection, such as
very rare, and is generally caused by abnor- tonsillitis or a retrotonsillar abscess. The infec-
mal weakness in the ligaments between the tion weakens the intervertebral ligaments and an
dens and the back of the skull and these are atlantoaxial subluxation is the result.
the apical ligament of the dens and the alar
ligaments (Fig. 2.6). This causes an occipi- Sandifer syndrome An acute painful stiff and
toatlantal subluxation and occurs in 60 % of possibly wry neck may occur as a result of

3
See Appendix.
Neck Pain 13

Fig. 2.7 Atlantoaxial Anterior


subluxation. Type I:
Rotatory displacement, the
transverse atlantal liga-
ment is intact. No anterior
shift. Type II: Rotatory
displacement. One of the
two atlantoaxial joints is
subluxated. The transverse
atlantal ligament is insuf-
ficient. Anterior shift of
3–5 mm. Type III: Rotatory
displacement. Both atlanto- Type I Type II
axial joints are subluxated.
Insufficient transverse
atlantal ligament. Anterior
shift of more than 5 mm.
Type IV: Posterior sublux-
ation. There is hypoplasia
or aplasia of the dens
(Redrawn from: Fielding
JW, Hawkins RJ. Atlanto-
axial rotatory fixation.
(Fixed rotatory subluxation
of the atlanto-axial joint).
J Bone Joint Surg Am.
1977;59-A:37–44) Type III Type IV

Posterior

Normal Hypoplasia Aplasia

Os terminale Os odontoideum

Fig. 2.8 Dens variations

heartburn caused by gastroesophageal reflux in Spondylodiscitis Older children usually have


young children, during or right after a meal. fever in addition to a painful stiff neck. Discitis
There is no atlantoaxial subluxation. is generally caused by staphylococcus aureus.
14 2 Neck

< 1 mm

Fig. 2.10 Wiesel-Rothman method for assessing


occipitoatlantal instability. Lateral craniometry: a hori-
zontal line is drawn that connects the anterior and poste-
rior borders of the atlas. A perpendicular line is drawn
touching the posterior border of the anterior arch. A sec-
ond perpendicular line is drawn from the anterior border
Fig. 2.9 Lateral X-ray of the cervical spine. Disc calcifi- of the foramen magnum. In flexion and extension images
cation at the C2-C3 level (arrow) the distance between the two perpendicular lines (distance
from occiput with respect to the atlas) should not exceed
1 mm (Redrawn from: Wiesel SW, Rothman RH. Occipito-­
The WBC count is normal or elevated, the CRP atlantal hypermobility. Spine. 1979;4:187–91)
is normal in 60 % of cases, and the ESR is usu-
ally elevated. The blood culture is positive in polyarticular type. Neck pain in the poly- or pau-
30 % of cases. ciarticular type is rare. A stiff and possible wry
A bone scan will show increased local activ- neck is rarely accompanied by pain. It is usually
ity within a week. Radiological images show caused by destruction of the occipitoatlantal
no abnormalities in the first instance. After joints or as a result of atlantoaxial subluxation.
10–14 days X-rays show a narrowing of the
intervertebral space with irregular end plates  Supplementary assessment: in the case of a
of the adjacent vertebral bodies. An MRI at an suspected occipitoatlantal or atlantoaxial
early stage shows an abnormal intervertebral subluxation, an anteroposterior and lateral
disc before abnormalities can be seen on a X-ray of the cervical spine should be taken. A
bone scan. dens image (antroposterior X-rays of C1-C2
with an open mouth), and flexion and exten-
Disc calcification The cause of disc calcifica- sion images of the cervical spine should be
tion is unknown. Disc calcifications can occur made. If abnormalities are seen on the X-rays
in the entire spinal column and in several additional CT-scans and MRIs should be
discs simultaneously. In 70 % of cases cervical taken. The Wiesel-Rothman method can be
(Fig. 2.9), mostly at the C6-C7 level and in 20 % used to assess occipitoatlantal instability. On
in the thoracic spine and in 10 % at both levels. the flexion and extension images the distance
Lumbar manifestations are rare. In 60 % of cases from the occiput with respect to the atlas
the radiological manifestation of the disc calcifi- should not exceed 1 mm (Fig. 2.10). The
cation disappears spontaneously. In addition to a atlantodental index (ADI) can be determined
painful stiff neck, one quarter of children get a in the case of atlantoaxial instability. In chil-
wry neck. In very exceptional situations there is a dren younger than age 8 this should be less
progressive neurological deterioration. than 4.5 mm and for older children it should
be less than 2 mm (Fig. 2.11).
Juvenile idiopathic arthritis An acute stiff and Spinal canals with an anteroposterior dia­
a wry neck can be the first symptom in juvenile meter (SAC = Space Available for Cord) of
idiopathic arthritis, usually of the systemic or less than 13 mm have a stenosis of the spinal
Neck Pain 15

SAC

3 - 4 kg

Fig. 2.12 Glisson sling

ADI
 When to refer: if there is no throat infec-
Fig. 2.11 Atlantodental index for atlantoaxial instability. tion, no gastroeso-phageal reflux, no disc
Lateral craniometry: the atlantodental index (ADI) is the calcification or juvenile idiopathic arthritis,
distance between the posterior border of the anterior arch or if acute pain has lasted for more than a
of the atlas and the anterior border of the dens. In children
younger than 8 years this distance should be less than week.
4.5 mm and in children older than 8 years it should be less
 Secondary care treatment: occipitoatlantal
than 2 mm. Spinal canals with a anteroposterior diameter
(SAC Space Available for Cord) of less than 13 mm have and atlantoaxial subluxation. Most patients
a canal stenosis with an increased risk of spinal cord com- whose symptoms have been present for less
pression (Redrawn from: Copley LA, Dormans than a week can be treated with a soft collar.
JP. Cervical spine disorders in infants and children. J Am
The soft collar is no longer required after the
Acad Orthop Surg. 1998;6:204–14)
symptoms disappear. It is recommended to
treat the subluxation by using traction with
canal with an increased risk of spinal cord
a Glisson sling if the symptoms have been
compression.
present for more than a week, (Fig. 2.12). A
If a discitis is suspected it is prudent to do an
CT-­scan should be taken to assess whether
MRI at an early stage in addition to determin-
the subluxation has been corrected. In this
ing the CRP and the ESR and taking blood
case, a follow-up treatment ensues with a
cultures. Disc calcification can be easily rec-
soft collar for 6 weeks. The subluxation
ognized on lateral X-rays of the cervical
must be corrected non-operatively under
spine. In juvenile idiopathic arthritis general-
anaesthetic, followed by immobilization for
ized abnormalities are often present shortly
3 months using a Minerva cast (Fig. 2.13)
before or after the neck problems appear, so
or a halo vest, if correction has not
the diagnosis is not very difficult to make.
been achieved or the traction is poorly
 Primary care treatment: start by checking tolerated.
whether there is a throat infection (Grisel In occipitoatlantal subluxations a spondy-
­syndrome) or heartburn caused by gastro- lodesis is almost never necessary. If the
esophageal reflux (Sandifer syndrome). symptoms last for more than a month, then
These underlying causes must be treated the chances of successful nonsurgical repo-
first. In addition analgesics and a soft cervi- sitioning is slight and a spondylodesis must
cal collar are given for the causes mentioned be carried out. If the atlantodental index
above. The collar can be removed after dis- (ADI) is between 5 and 10 mm, contact
appearance of the symptoms. If X-rays show sports and diving must be avoided and even
disc calcification this can also be treated a prophylactic C1-C2 spondylodesis should
with analgesics and a soft collar as long as be considered. In the case of an atlantoden-
symptoms are present. The worst complaints tal index of more than 10 mm a C1-C2
will disappear after 7–10 days. NSAID’s can spondylodesis is performed regardless of
be given for juvenile idiopathic arthritis. symptomatology.
16 2 Neck

Table 2.2 Tumors that cause metastasis in the spine


Adenocarcinoma
Ewing sarcoma
Neuroblastoma
Rhabdomyosarcoma
From: Freiberg AA, Graziano GP, Loder RT, Hensinger
RN. Metastatic vertebral disease in children. J Pediatr
Orthop. 1993;13:148–53

Table 2.3 Primary spinal column tumors. The tumors


identified with the § sign are rare
Benign Malignant
Aneurysmal bone cyst Ewing sarcoma
Chordoma Lymphoma §
Endochondroma Osteosarcoma §
Eosinophilic granuloma
Osteoblastoma
Osteoid osteoma
Based on Adler CP, Kozlowski K. Primary bone tumors and
tumorous conditions in children. Springer Verlag; 1993

Table 2.4 Primary spinal cord tumors


Benign Malignant
Lipoma Astrocytoma
Neurofibroma Ependymoma
Spinal cyst Oligodendroglioma
Fig. 2.13 Minerva cast
may or may not be accompanied by a wry
neck and pain.
Spondylodiscitis A discitis is treated with some
 Assessment: mobility of the cervical spine is
form of immobilization and antibiotics. The
severely limited or absent, and there may be
staphylococcus aureus should in any event be
a wry neck.
sensitive to the administered antibiotics. This
treatment is continued until CRP and BSE levels  Differential diagnosis:
are normal. The process usually takes 6–8 weeks.
metastases
primary bone tumor
Juvenile idiopathic arthritis In severe abnor-
primary spinal cord tumor
malities at the level of the craniocervical junction
an occipitoatlantal or atlantoaxial spondylodesis  Explanatory note: metastases. Metastases
or a combination of these can be considered. are the most frequent tumors (Table 2.2).

Primary bone tumor In children most primary


 low Onset Painful Stiff and Possibly
S bone tumors are benign (Table 2.3). All of these
Wry Neck tumors may give compression, mostly to the spi-
nal nerve roots and not the spinal cord.
 
Complaint: the mobility of the neck
decreases gradually and at a certain point in Primary spinal cord tumor Most primary spi-
time the patient will have a stiff neck. This nal cord tumors are malignant (Table 2.4). Spinal
Neck Pain 17

Table 2.5 Tumors with an increased risk of spinal cord  Differential diagnosis:
compression in children
Spinal cord compression cervical kyphosis
Astrocytoma basilar impression
Lymphoma primary type
Neuroblastoma secondary type
Sarcoma (in particular Ewing sarcoma) Arnold-Chiari malformation
From: Conrad EU. Pediatric spine tumors with spinal cord stenosis of the foramen magnum
compromise. J Pediatr Orthop. 1992;12:454–60
congenital occipitoatlantal synostosis
hypoplasia or aplasia of the dens
os odontoideum tumor
cord tumors at the cervical level are usually
accompanied by muscle weakness and coordina-  Explanatory note: cervical kyphosis (see p. 8).
tion disorders (Table 2.5). Sometimes they can be
very slow-growing and only cause a stiff or
Basilar impression In a basilar impression the
­possible wry neck as the sole symptom at the
dens of the axis lies too high in the foramen mag-
moment of assessment.
num. As a result of this, in nearly 80 % of basilar
impressions there is a short neck and in 70 % of
 
Supplementary assessment: in addition to
cases a wry neck. Structures in the posterior cra-
X-rays, a CT-scan and MRI of the cervical
nial fossa (cerebellum and brainstem) have too
spine and brain should be carried out.
little space because of the elevated position of the
 
Primary care treatment: the primary care dens. There are two types of basilar impression:
provider, usually the general practitioner, primary and secondary.
must suspect that a single symptom such as
only a slow onset stiff neck may be a sign of Primary type This is a congenital abnormality
a serious abnormality. and is often associated with other anomalies of the
 When to refer: every patient with a slow neck vertebrae such as occipitoatlantal synostosis,
onset stiff neck should be referred. an abnormal dens and the Klippel-Feil syndrome4.

 Secondary care treatment: tumor. Treatment Secondary type This type is the result of weaken-
of spinal column and spinal cord tumors must ing of the bony (base of the skull) structures as may
take place in a specialized medical center. be seen in rachitis and osteogenesis imperfecta4. In
The treatment is usually surgical, depending 85 % of basilar impression cases there is a paresis
on the nature of the tumor and/or radiother- and paresthesia of the extremities. There may also
apy and/or chemotherapy may be necessary. be difficulties with swallowing resulting from
compression of the cranial nerves IX, X and XII.
 ainful Stiff and Possibly Wry Neck
P
with Neurological Symptoms Arnold-Chiari malformation Arnold-Chiari
malformation is caused by a caudal displacement
 Complaint: painful, possibly wry neck accom- of the tonsils of the cerebellum into the foramen
panied by neurological symptoms. magnum. This deformity is accompanied by a
basilar impression in half of all cases. Symptoms
 Assessment: the most noticeable are symp- tend to arise between the ages of 10 and 30. In
toms of the neurological deterioration. There addition to neck pain there is often a forced neck
may be a nystagmus, cerebellar ataxia caus- posture, accompanied by cerebellar and v­ estibular
ing lack of ordered locomotion, swallowing
disorders and symptoms of headache and
dizziness. 4
See Appendix.
Another random document with
no related content on Scribd:
valuable as exhibiting the kind of passion which love showed itself in
Wordsworth. Passion, in the proper meaning of the word—viz., deep, fiery,
intense, and all-embracing feeling, was certainly not Wordsworth’s. His
love was calm, intellectual, and emotional—but it was not passion. All his
love seems to have passed through his head before it touched his heart. And
yet he loved his wife, and lived, as I said before, very happily with her.
Mrs. Wordsworth, however, was a true household woman, and had not
acquired that faculty of walking which Wordsworth and his sister
possessed, in so eminent a degree. In about a year, therefore, after his
marriage—that is, August 14, 1803,—we find Wordsworth parting from his
wife, and making a tour into Scotland, with his sister and Coleridge, taking
Carlisle on the way. When they arrived at Longtown, they found a guide-
post pointing out two roads,—one to Edinburgh, the other to Glasgow. They
took the latter road, and entered Scotland by crossing the river Sark.
Edinburgh was no favourite place with Wordsworth, and for reasons which
are sufficiently obvious. The tourists then passed through Gretna Green to
Annan, leaving the Solway Frith, and the Cumberland hills to their left
hand. On Thursday the 18th August, they went to the churchyard where
Burns is buried; a bookseller accompanied them, of whom Miss
Wordsworth had bought some little books for Johnny, the poet’s first child.
He showed them first the outside of Burns’ house, where he had lived the
last three years of his life, and where he died. It had a mean appearance, and
was in a bye situation, white-washed, and dirty about the doors, as all
Scotch houses are; flowering plants in the windows. They went on to visit
his grave. He lies in a corner of the churchyard, and his second son, Francis
Wallace, is beside him. There was no stone to mark the spot. The greatest
bard that had sung in Britain for some centuries, lay buried there like a dog.
A hundred guineas, however, had been collected to build a monument over
his ashes. “There,” said the bookseller to the visitors, pointing to a pompous
monument, a few yards off, “there lies Mr. John Bushby, a remarkably
clever man; he was an attorney, and hardly ever lost a cause he undertook.
Burns made many a lampoon upon him; and there they rest as you see.”
Yes, indeed, there they rested; and that was the deep, sad moral of the story.
We shall all rest so at last. They then went to Burns’ house. Mrs. Burns was
not at home, but had gone to the sea-shore with her children. They saw the
print of “The Cotter’s Saturday Night,” which Burns mentioned in one of
his letters having received as a present. In the room above the parlour Burns
died, and his son after him; and of all who saw this parlour on this 18th of
August,—Wordsworth and his sister, Coleridge and the poor bookseller—
who survives? “There they rest, as you see.”
The tourists travelled subsequently through the Vale of the Nith, and
crossing the Frith, reached Brownhill, where they slept.
“I cannot take leave of this country,” says Miss Wordsworth, in her
Journal, “without mentioning that we saw the Cumberland mountains
within half a mile of Ellisland (Burns’ house) the last view we had of them.
Drayton has prettily described the connection which the neighbourhood has
with ours, when he makes Skiddaw say—

‘Scurfell from the sky,


That Annandale doth crown, with a most amorous eye,
Salutes me every day, or at my pride looks grim,
Oft threatening me with clouds, as I oft threatening him!’

These lines occurred to William’s memory; and while he and I were talking
of Burns, and the prospect he must have had, perhaps from his own door, of
Skiddaw and his companions, we indulged ourselves in fancying that we
might have been personally known to each other, and he have looked upon
those objects with more pleasure for our sakes. We talked of Coleridge’s
children and family, then at the foot of Skiddaw, and our own new-born
John, a few miles behind it; and the grave of Burns’ son, which we had just
seen, by the side of that of his father; and the stories we had heard at
Dumfries, respecting the dangers which his surviving children were
exposed to, filled us with melancholy concern, which had a kind of
connection with ourselves, and with thoughts, some of which were
afterwards expressed in the following supposed address to the sons of the
ill-fated poet:—

“Ye now are toiling up life’s hill,


’Tis twilight time of good and ill!”

During this Scotch tour the party walked through the vale of the Clyde,
visited Glengyle, the scene of some of Rob Roy’s exploits, Loch Lomond,
Inverary, Glencoe, Kenmore, and the Duke of Athol’s gardens; resting
whilst in this latter place on “the heather seat which Burns was so loth to
quit that moonlight evening when he first went to Blair Castle.” Then they
went to the Pass of Killicranky, respecting which Wordsworth wrote the
following sonnet.

“Six thousand veterans practis’d in war’s game,


Tried men, at Killicranky were arrayed
Against an equal host that wore the plaid,
Shepherds and herdsmen. Like a whirlwind came
The Highlanders; the slaughter spread like flame;
And Garry, thundering down his mountain road,
Was stopped, and could not breathe beneath the load
Of the dead bodies! ’Twas a day of shame
For them whom precept, and the pedantry
Of cold mechanic battle do enslave.
Oh for a single hour of that Dundee,
Who on that day the word of onset gave!
Like conquest might the men of England see!
And their foes find a like inglorious grave.

In the year 1803, when this sonnet was written, an invasion was hourly
looked for; and Miss Wordsworth and her brother (for Coleridge had left
them, worried by the “evil chance,” and something worse perhaps at Loch
Lomond) could not but think with some regret of the times when from the
now depopulated Highlands, forty or fifty thousand men might have been
poured down for the defence of the country, under such leaders as the
Marquis of Montrose, or the brave man who had so distinguished himself
upon the ground where they were standing.
The tourists returned by way of Edinburgh, visiting Peebles and Melrose
Abbey. Sir Walter, then Mr. Scott, was, at the time of their visit to the
abbey, travelling as Sheriff of Selkirk to the assizes at Jedburgh. They dined
together at the Melrose Inn. Sir Walter was their guide to the abbey, taking
them into Mr. Riddel’s gardens and orchard, where they had a sweet view of
it through trees, the town being quite excluded. Sir Walter was of course at
home in the history and tradition of these noble ruins, and pointed out to his
visitors many things which would otherwise have escaped their notice.
Beautiful pieces of sculpture in obscure corners, flowers, leaves, and other
ornaments, which being cut in the durable pale red stone of which the abbey
is built, were quite perfect. What destroyed, however, the effect of the
abbey, was the barbarous taste of the good Scotch people who had built an
ugly, damp charnel house within the ruins, which they called a church!
Quitting Melrose, they crossed the Teviot by a stone bridge, and visited
Jedburgh. It rained all the way, and they arrived at the inn just before the
judges were expected out of court to dinner, very wet and cold. There was
no private room but the judges’ sitting-room, and they had to get private
lodgings in the town. Scott sat with them an hour in the evening, and
repeated a part of his “Lay of the Last Minstrel.” Their landlady was a very
remarkable woman; and Wordsworth wrote some verses expressive of the
feelings with which she inspired him. Here is the burden.

“Aye! twine thy brows with fresh spring flowers,


And call a train of laughing hours,
And bid them dance, and bid them sing,
And thou, too, mingle in the ring.”

Miss Wordsworth gives the following sweet picture of the home at


Grasmere on their return:—
“September 25th.—A beautiful autumnal day. Breakfasted at a public-
house by the road-side; dined at Threlkeld; and arrived there between eight
and nine o’clock, where we found Mary in perfect health. Joanna
Hutchinson with her, and little John asleep in the clothes-basket by the
fire.”
At the ferry-house, and waterfall of Loch Lomond, Wordsworth had
been struck with the beauty and kindness of two girls whom they met there,
and on his return to Grasmere he wrote the following lines upon one of
them:—
“Sweet Highland girl, a very shower
Of beauty is thy earthly dower!
Twice seven consenting years have shed
Their utmost bounty on thy head:
And these grey rocks; this household lawn;
These trees, a veil just half withdrawn;
This fall of water that doth make
A murmur near the silent lake;
This little bay, a quiet road,
That holds in shelter thy abode;
In truth together ye do seem
Like something fashioned in a dream;
Such forms as from their covert peep
When earthly cares are laid asleep.
Yet dream and vision as thou art,
I bless thee with a human heart:
God shield thee to thy latest years!
I neither know thee, nor thy peers;
And yet my eyes are filled with tears.”

This Scottish tour was a little episode in the quiet history of the poet’s
residence at Grasmere. The truth is, that Wordsworth could not at this time
rest long, even in his beautiful Grasmere, without the excitement of
pedestrian travel and adventure. It was likewise a part of his education as a
poet; the knowledge which he thus acquired of men, manners, and scenery.
He had devoted himself to poetry; and every thing that tended to feed the
divine faculty, he grasped at with an avidity equally as intense as that with
which your mere canine man grasps at food for his perishing body. Nothing
comes amiss to him; high and low, great and small; from the daffodil to
Skiddaw—from Skiddaw to heaven and its hosts of glorious stars,—all are
seized by this omnivorous poet, fused in his mind, and reproduced by him
in song. His limited means are no barrier to his wanderings; he and his
sister can live upon black bread and water, so far as rations are concerned;
but setting aside the necessity of the case, this economy is for a sacred
purpose,—viz.:—that they may enjoy the communion of Nature, and
partake of her spiritual banquets. The gods, however, had determined to pet
Wordsworth, and recompense him for his religious devotion to their doings
through early life; and, to say nothing of the bequest of Raisley Calvert, the
second Lord Lonsdale, just as the poet needed a wife, and larger means,
paid the debt which his predecessor owed to Wordsworth’s father,
amounting to £1,800, as the share of each member of the family. This was a
most fortunate circumstance to Wordsworth and his sister; though it
mattered little to the rest, because they were well appointed in life. De
Quincy says that, a regular succession of similar, but superior, God-sends
fell upon Wordsworth, to enable him to sustain his expenditure duly, as it
grew with the growing claims upon his purse; and after enumerating the
three items of “good luck,” mentioned above, he adds:—and “fourthly,
some worthy uncle of Mrs. Wordsworth’s was pleased to betake himself to
a better world; leaving to various nieces, and especially to Mrs. W.,
something or other, I forget what, but it was expressed by thousands of
pounds. At this moment Wordsworth’s family had begun to increase; and
the worthy old uncle, like every body else in Wordsworth’s case (I wish I
could say the same in my own), finding his property clearly ‘wanted,’ and
as people would tell him ‘bespoke,’ felt how very indelicate it would look
for him to stay any longer, and so he moved off. But Wordsworth’s family,
and the wants of that family, still continued to increase; and the next person,
being the fifth, who stood in the way, and must, therefore, have considered
himself rapidly growing into a nuisance, was the Stamp-Distributor for the
county of Westmorland. About March, 1814, I think it was, that this very
comfortable situation was vacated. Probably it took a month for the news to
reach him; because in April, and not before, feeling that he had received a
proper notice to quit, he, good man—this Stamp-Distributor—like all the
rest, distributed himself and his offices into two different places,—the latter
falling of course into the hands of Wordsworth.
“This office, which it was Wordsworth’s pleasure to speak of as a little
one, yielded, I believe, somewhere about £500 a year. Gradually even that,
with all former sources of income, became insufficient; which ought not to
surprise anybody; for a son at Oxford, as a gentleman-commoner, could
spend at least £300 per annum; and there were other children. Still it is
wrong to say, that it had become insufficient; as usual it had not come to
that; but, on the first symptoms arising that it would soon come to that,
somebody, of course, had notice to consider himself a sort of nuisance elect,
—and in this case it was the Distributor of Stamps for the county of
Cumberland.” And in this strain of good-humoured banter—stimulated no
doubt by his own precarious circumstances, in a measure, circumstances
which ought not in his case to be precarious,—De Quincy relates how
another £400 a year was added to the poet’s income from the increase of his
district as Stamp-Distributor.
In 1842, since De Quincy wrote the above, Wordsworth resigned this
office, and it was bestowed upon his son,—whilst he (the poet,) was put
down upon the Civil-list for £300 a year, and finally made Poet Laureate.
To return, however, to the more even tenor of these Memoirs:—A
circumstance occurred in the year 1803, shortly after the Scottish tour,
which will further illustrate the “good luck” of Wordsworth, although in this
instance he did not avail himself of it. Sir George Beaumont, the painter,
out of pure sympathy with the poet,—and before he had seen or written to
him,—purchased a beautiful little estate at Applethwaite, near Keswick, and
presented it to him, in order that he (Wordsworth) and Coleridge, who was
then residing at Greta Hall, might have the pleasure of a nearer and more
permanent intercourse. A fragment of Sir George’s letter (good Sir George,
who could recognise genius, and was noble and generous enough to prove
his recognition in a most practical form) is printed in Dr. Wordsworth’s
“Memoirs,” and it shews what a fine heart he had, God bless him! It is
dated October 24, 1803, and runs thus:—
“I had a most ardent desire to bring you and Coleridge together. I
thought with pleasure on the increase of enjoyment you would receive from
the beauties of Nature, by being able to communicate more frequently your
sensations to each other, and that this would be the means of contributing to
the pleasure and improvement of the world, by stimulating you both to
poetic exertions.” The benevolent project of this excellent baronet was
defeated, partly because Coleridge soon after left Greta Hall for a warmer
climate, being impelled to this course by ill health, and partly from private
considerations respecting Wordsworth and his family, which, however, do
not transpire in the “Memoirs.” A curious fact in connection with this gift
of Sir George is, that Wordsworth neglected to thank the donor, or to take
the slightest notice of it, for eight weeks after the writings were placed in
his hands. In a letter addressed to the baronet, dated Grasmere, October
14th, 1803, Wordsworth apologises for this apparent neglect, and attributes
it partly to the overpowering feelings with which the gift inspired him, and
partly to a nervous dread of writing, and a fear lest he should acknowledge
the honour that had been done him in an unworthy manner. “This feeling,”
he says, “was indeed so very strong in me, as to make me look upon the act
of writing to you, not as the work of a moment, but as a thing not to be
done, but in my best, my purest, my happiest moments.” Thus strangely
began one of the few friendships which Wordsworth cultivated with men,
and one which lasted through the life of the noble-hearted baronet, who, in
dying, in the year 1827 (on the 7th of February), left Wordsworth an
annuity of £100 to defray the expenses of an annual tour. (Another instance
of the poet’s “good luck!”) It is right to add, that Wordsworth was deeply
affected by his friend’s death, and that he has left, in his “Elegiac Musings,”
some noble lines to his memory.
Amongst the occasional visitors at Grasmere between the years 1800 and
1804, was Captain John Wordsworth, the poet’s second brother, who was
eventually lost in the Abergaveny East Indiaman, on the 5th of February,
1804. His brother was a man of fine taste and discernment, and prophesied
in various letters and at various times, the ultimate success of Wordsworth’s
poetry. Wordsworth felt severely the untimely death of his brother, whom
he loved with that devoted family fondness, which was characteristic of
him. Writing to Sir George Beaumont upon this event, he says: “February
11th, 1808. This calamitous news we received at two o’clock to-day; and I
write to you from a house of mourning. My poor sister, and my wife, who
loved him almost as we did (for he was one of the most amiable of men) are
in miserable affliction, which I do all in my power to alleviate; but, Heaven
knows, I want consolation myself. I can say nothing higher of my ever dear
brother than that he was worthy of his sister, who is now weeping beside
me, and of the friendship of Coleridge; meek, affectionate, silently
enthusiastic, loving all quiet things, and a poet in everything but words.”
The lyre of the poet sounded his praises in three poems. The first is entitled
“Elegiac Stanzas suggested by a picture of Peel Castle in a storm, painted
by Sir George Beaumont.” The next is “To a Daisy,” which suggests his
brother’s love of quiet and peaceful things, and closes with the tragedy of
his death, and the discovery and final burial of the body in the country
churchyard of Wythe, a village near Weymouth.

“And thou, sweet flower, shalt sleep and wake,


Upon his senseless grave,”

he concludes, returning thus finely to the simple flower which suggested the
melancholy train of thought that runs through the poem. The third of these
sad lyrical verses refers to the scene where the poet bade his brother
farewell, on the mountains from Grasmere to Patterdale. The verses upon
the “Picture of Peel Castle,” is the best of all these pieces; and as a fitting
conclusion to this brief memorial of the poet’s brother, I will transcribe it.

“I was thy neighbour once, thou rugged pile!


Four summer weeks I dwelt in sight of thee:
I saw thee every day; and all the while
Thy form was sleeping on a glassy sea.

So pure thy sky, so quiet was the air!


So like, so very like, was day to day!
Where’er I looked, thy image still was there;
It trembled, but it never passed away.

How perfect was the calm! it seemed no sleep;


No mood, which season takes away or brings:
I could have fancied that the mighty deep
Was even the gentlest of all gentle things.

Ah! then, if mine had been the painter’s hand,


To express what then I saw; and add the gleam,
The light that never was on sea, or land,
The consecration, and the poet’s dream;

I would have planted thee, thou hoary pile!


Amid a world how different from this!
Beside a sea that could not cease to smile
On tranquil land, beneath a sky of bliss.

A picture had it been of lasting ease,


Elysian quiet, without toil or strife;
No motion but the moving tide, a breeze,
Or merely silent Nature’s breathing life.

Such, in the fond illusion of my heart,


Such picture would I at that time have made;
And seen the soul of truth in every part,
A steadfast peace that might not be betrayed.

So once it would have been—‘tis so no more;


I have submitted to a new control;
A power is gone, which nothing can restore;
A deep distress hath humanised my soul.
Not for a moment could I now behold
A smiling sea, and be what I have been;
The feeling of my loss will ne’er be old;
This, which I know, I speak with mind serene.

Then, Beaumont, friend! who would have been the friend,


If he had lived, of him whom I deplore,
This work of thine I blame not, but commend;
This sea in anger, and that dismal shore.

O ’tis a passionate work!—yet wise and well;


Well chosen is the spirit that is here;
That hulk, which labours in the deadly swell,
This rueful sky, this pageantry of fear!

And this huge castle, standing here sublime,


I love to see the look with which it braves,
Cased in the unfeeling armour of old time,
The lightning, the fierce wind, and trampling waves.

Farewell, farewell, the heart that lives alone,


Housed in a dream, at distance from the kind!
Such happiness, wherever it be known,
Is to be pitied, for ’tis surely blind.

But welcome fortitude, and patient cheer,


And frequent sights of what is to be borne!
Such sights, or worse, as are before me here.—
Not without hope we suffer, and we mourn.”
—1805.

About a month after his brother’s death, Wordsworth concluded his


“Prelude,” upon which he had been employed for upwards of six years. In
allusion to this poem, Coleridge, in the “Table Talk,” says: “I cannot help
regretting that Wordsworth did not first publish his thirteen books (there are
fourteen of them,) “On the growth of an individual mind,”—superior, as I
used to think, on the whole, to the “Excursion!” ... Then the plan laid out,
and I believe partly suggested by me was, that Wordsworth should assume
the station of a man in mental repose, one whose principles were made up,
and so prepared to deliver upon authority a system of philosophy. He was to
treat man as man, a subject of eye, ear, touch and taste, in contact with
external nature, and inferring the senses from the mind, and not
compounding a mind out of the senses; then he was to describe the pastoral
and other states of society, assuming something of the Juvenalian spirit as
he approached the high civilization of cities and towns, and opening a
melancholy picture of the present state of degeneracy and vice; thence he
was to infer and reveal the proof of, and necessity for, the whole state of
man and society being subject to, and illustrative of, a redemptive process
in operation, showing how this idea reconciled all the anomalies, and
promised future glory and restoration.”
Wordsworth himself unfolds his own plan of the poem to Sir George
Beaumont, in a letter dated December 25th, 1804. It was to consist, first of
all, of a poem to be called “The Recluse,” wherein the poet was to express
in verse, his own feelings concerning Man, Nature, and Society—and,
secondly, a poem on his earlier life or the growth of his own mind. This
latter poem was “The Prelude,” two thousand verses of which, he says, in
the same letter, he had written during the last ten weeks. “The Prelude,”
therefore, which was not published till after the poet’s death, was first
written, and “The Recluse,” subsequently. Only a part of this poem,
however—viz., “The Excursion,” except, of course, “The Prelude,” is
published; “The Recluse” Proper, being still in MS.
Besides these larger works, Wordsworth threw off—not without care and
meditation,—for no man ever wrote with more method and purpose—many
minor poems, and amongst them was “The Waggoner,” dedicated to
Charles Lamb, but not published until 1819. It was in this year (1805) that
Wordsworth, Sir Walter Scott, and Sir Humphry Davy ascended Helvellyn
together; and learned the sad story of poor Charles Gough, who perished in
attempting to cross over Helvellyn to Grasmere, by slipping from a steep
part of the rock, where the ice was not thawed, and beside whose remains
his faithful dog was found many days afterwards, almost starved to death.
This affecting incident afforded a theme for both poets—viz., Sir Walter
and Wordsworth, and each wrote upon it without knowing that the other
was similarly engaged. Scott’s poem is entitled “Helvellyn,” and
Wordsworth’s “Fidelity.”
In 1807, Wordsworth issued two new volumes of poetry, in 12mo.,
which contained some of his best pieces; but which, like all his poems, did
not gain immediate popularity. It is true that a fourth edition of the “Lyrical
Ballads” had been called for, and that this indicated a growing taste in the
public mind for Wordsworth’s effusions; but the critics assailed him with
the bitterest animosity, and on the whole without much reason. With no
reason, in short, so far as the poetic principles—the canon of his poetry—
was concerned, and only with some show of reason in the instance of his
peculiar mannerism. For although he was often misled by his craving after
simplicity, and uttered what might be called without any violation of truth
or desecration of the poet’s name and memory—drivel—still he had
published poems of a very high order, such as had not been published in the
lifetime of any man then living. The critics, however, could not let him
alone, could not see the manifest beauties of his poetry, or would not see
them, but denounced the whole without reserve or mercy. In the meanwhile
Coleridge cheered him on, and on his return to England, in the summer of
1806, Wordsworth read “The Prelude” to him in the gardens of Coleorton,
near Ashby-de-la-Zouch, Leicestershire, where the poet was then residing at
the invitation of Sir George Beaumont; and the high commendations which
Coleridge poured upon this poem animated Wordsworth to increased
exertion and perseverance. During his residence at this beautiful house, he
composed the noble “Song at the Feast of Brougham Castle,”—the finest
thing of the kind in our language; and he left behind him as usual, many
records of his feelings at Coleorton. The poet’s letters to Sir George
Beaumont and an occasional one to Sir Walter Scott, are amongst the most
interesting transcripts we have of his mind at this period.
It was in the beginning of the winter, 1807, that De Quincy paid his first
visit to Wordsworth; and I find great fault with Dr. Wordsworth that he
makes no allusion to De Quincy in all his memoirs of the poet. This is the
more unpardonable, inasmuch as De Quincy is a man of the highest calibre
—of the most refined taste,—of the profoundest scholarship, and possessing
the widest acquaintance with general literature—to say nothing of his
transcendant genius—of any man who has lived in this generation.
Unpardonable, likewise, because De Quincy was a devout lover, and a
chivalrous defender of Wordsworth, when it was not fashionable to speak
well of him, and when a man who praised him stood a fair chance of being
estimated, if not called, a madman. Neither can I ever forgive the poet
himself for his cold neglect of the great Opium Eater. Such a man as De
Quincy is not to be treated with contumely and despite, even by such a man
as Wordsworth; for assuredly, in point of genius, both men stood pretty
much upon the same level, and Wordsworth was far inferior to De Quincy
in the other important matters specified above. De Quincy’s demon did not
inspire him to write verses, but to write essays—and what essays! I do not
know the writer who has ever taken so wide a range of subjects, and written
upon them in such grand and noble English. De Quincy was a prose
architect, Wordsworth a poetic one; and this is all the difference between
them. In genius they were equal. Some day, perhaps, De Quincy will be
better appreciated. We are indebted to De Quincy for the best account
existing of the poet, his family, and home at Grasmere and Rydal; and no
one would go to Dr. Wordsworth for information when he could go to De
Quincy. Not that I have anything to say against Dr. Wordsworth personally,
but I dislike his studied exclusiveness. The men who for long years were in
constant intercourse with the poet, and on terms of friendship with him—
Wilson, for example, as well as De Quincy—cannot be shut out from his
biography without manifest injustice both to them and to the poet; and yet
this is systematically done. Perhaps the good doctor has a clerical horror of
his great-uncle being associated with loose Men of Letters; men, too, of not
quite an orthodox cast in their opinions; genial, jovial, and full of all good
fellowship besides. But of what avail could such horror so manifested be?
The world will know the truth at last; and it is right they should; and one
thing is certain enough, that Wordsworth will suffer no dishonour in the
companionship of De Quincy and Wilson.
When I first read No. 1, of the “Lake Reminiscences,” by De Quincy, in
“Tait’s Magazine,” I could scarcely believe what I read; and nothing would
have convinced me of its truth, short of the authority which announced it. I
had looked upon Wordsworth as a kind-hearted, generous, and unselfish
man; noble, friendly, and without the vanity which has so often blurred the
fair page of a great man’s nature. I was sorry to find that I was mistaken in
this estimate of the poet; and that he, like me, and all the rest of us, had
faults and failings manifold. De Quincy’s own account of his first visit to
Wordsworth, the deep reverence with which he regarded him, and the
overwhelming feelings which beset him on the occasion, is very affecting;
and contrasted with the poet’s subsequent treatment of him, his wanton
throwing away of that noble and affectionate heart, and his total disregard
of the high intellectual homage which De Quincy offered to him, is still
more affecting, and full, likewise, of pain and sorrow. Whilst he was a
student at Oxford, De Quincy twice visited the Lake Country, on purpose to
pay his respects to Wordsworth; and once, he says, he went forward from
Coniston to the very gorge of Hammerscar, “from which the whole vale of
Grasmere suddenly breaks upon the view in a style of almost theatrical
surprise, with its lovely valley stretching in the distance, the lake lying
immediately below, with its solemn boat-like island, of five acres in size,
seemingly floating on its surface; its exquisite outline on the opposite shore,
revealing all its little bays, and wild sylvan margin, feathered to the edge
with wild flowers and ferns!
“In one quarter a little wood, stretching for about half a mile towards the
outlet of the lake, more directly in opposition to the spectator; a few green
fields: and beyond them, just two bow-shots from the water, a little white
cottage gleaming from the midst of trees, with a vast and seemingly never-
ending series of ascents, rising above it to the height of more than three
thousand feet. That little cottage was Wordsworth’s, from the time of his
marriage, until 1808. Afterwards, for many a year, it was mine. Catching
one glimpse of this loveliest of landscapes, I retreated, like a guilty thing,
for fear I might be surprised by Wordsworth, and then returned faint-hearted
to Coniston, and so to Oxford, re infecta.—This was in 1806. And thus,
from mere excess of nervous distrust in my own powers for sustaining a
conversation with Wordsworth, I had for nearly five years shrunk from a
meeting for which, beyond all things under heaven, I longed.”
This nervous distrust yielded in after life to a sober confidence, and a
matchless power of unfolding his thoughts colloquially. In the meanwhile,
that is to say, in 1807, Coleridge returned from Malta, and De Quincy was
introduced to him first of all at Bridgewater, and met him again at the Hot-
wells, near Bristol,—when, upon discovering that he was anxious to put his
wife and children under some friendly escort, on their return homewards to
Keswick, De Quincy offered to unite with Mrs. Coleridge in a post-chaise
to the north. Accordingly they set out. Hartley Coleridge was then nine
years old, Derwent about seven, and the beautiful little daughter about five.
In such companionship, then, did De Quincy pay his first visit to
Wordsworth, at Grasmere,—a most interesting and artistic account of which
he has written in “Tait’s Magazine,” and to which I have been frequently
indebted in the compilation of these Memoirs. The cottage has already been
described, and the reader who has followed the course of this imperfect
history, will remember the portraits of its illustrious inmates. Let us now see
how it fared with De Quincy, when he met the mighty man of his heart. He
was “stunned,” when Wordsworth shook him cordially by the hand, and
went mechanically towards the house, leaving Mrs. Coleridge in the chaise
at the door. The re-appearance of the poet, however, after exercising due
hospitality to his lady guest, gave him courage, and he found that the said
poet was, after all, but a man. His reverence for him, however, continued
unabated, and for twenty-five years, during which time De Quincy lived at
the lakes, in constant communion with Wordsworth, his reverence for the
poet’s genius remained the same, and still remains, although he has long
since ceased to respect him in so highly as a man; not, however, because
Wordsworth was not of unimpeachable character, and estimable in so many
ways, but because he had not that generous love for his friends which
friendship demands. De Quincy confesses his estrangement from the poet
with sorrow, and some bitterness of heart; and the following extract will
throw all the light upon this subject which can be thrown at present:—
“I imagine a case such as this which follows,” says De Quincy, in
alluding to the estrangement spoken of above—“the case of a man who for
many years has connected himself with the domestic griefs and joys of
another, over and above his primary service of giving to him the strength
and the encouragement of a profound literary sympathy, at a time of
universal scorning from the world; suppose this man to fall into a situation,
in which, from want of natural connections, and from his state of insulation
in life, it might be most important to his feelings that some support should
be lent to him by a friend having a known place and acceptation, and what
may be called a root in the country, by means of connections, descent, and
long settlement. To look for this might be a most humble demand on the
part of one who had testified his devotion in the way supposed. To miss it
might—— But enough. I murmur not; complaint is weak at all times; and
the hour is passed irrevocably, and by many a year, in which an act of
friendship so natural, and costing so little (in both senses so priceless),
could have been availing. The ear is deaf that should have been solaced by
the sound of welcome. Call, but you will not be heard; shout aloud, but your
‘ave!’ and ‘all hail!’ will now tell only as an echo of departed days,
proclaiming the hollowness of human hopes. I, for my part, have long
learned the lesson of suffering in silence; and also I have learned to know
that, wheresoever female prejudices are concerned, there it will be a trial,
more than Herculean, of a man’s wisdom, if he can walk with an even step,
and swerve neither to the right nor to the left.”
Leaving this sad subject, however, let us return to De Quincy at
Grasmere in 1807. Mrs. Coleridge, on leaving the poet’s family for
Keswick, invited De Quincy to visit her and Southey, and it was arranged
that Wordsworth and the Opium Eater should go together. Accordingly they
set off in a farmer’s cart to Ambleside, and from thence mounted the ascent
of Kirkstone. Descending towards Brothers’ Water—“a lake which lies
immediately below; and about three miles further, through endless woods,
and under the shade of mighty fells, immediate dependencies and processes
of the still more mighty Helvellyn” they approached the vale of Patterdale,
and reached the inn, by moonlight. “All I remember,” says De Quincy is
—“that through those romantic woods and rocks of Stybarren—through
those silent glens of Glencoin and Glenridding—through that most romantic
of parks then belonging to the Duke of Norfolk—viz., Gobarrow Park—we
saw alternately for four miles, the most grotesque and the most awful
spectacles—
——“Abbey windows
And Moorish temples of the Hindoos,”

all fantastic, all as unreal and shadowy as the moon-light which created
them; whilst at every angle of the road, broad gleams came upwards of
Ullswater, stretching for nine miles northward, but fortunately for its effect,
broken into three watery channels of about equal length, and rarely visible
at once.”
The party, (for Miss Wordsworth and the poet’s children were present on
this occasion,) passed the night in a house called Ewsmere, and in the
morning, leaving his family at this inn, the poet set out, with De Quincy, for
a ramble through the woods of Lowther. These are the woods concerning
which the poet, in a letter to Sir George Beaumont, dated October 17, 1805,
says:—“I believe a more delightful spot is not under the sun. Last summer I
had a charming walk along the river, for which I was indebted to this man
[alluding to a good quaker, who was Lord Lowther’s arbiter elegantiarum,
or master of the grounds, and who was making improvements in them, by
virtue of his office], whose intention is to carry the walk along the river side
till it joins the great road at Lowther Bridge, which you will recollect, just
under Brougham, about a mile from Penrith. This, to my great sorrow! for
the manufactured walk, which was absolutely necessary in many places,
will, in one place, pass through a few hundred yards of forest-ground, and
will there efface the most beautiful specimen of forest pathway ever seen by
human eyes, and which I have paced many an hour when I was a youth,
with one of those I best loved. There is a continued opening between the
trees, a narrow slip of green turf, besprinkled with flowers, chiefly daisies;
and here it is that this pretty path plays its pranks, weaving among the turf
and flowers at its pleasure.” And it was in these woods, just five days after
their introduction to each other, that Wordsworth and De Quincy spent a
whole glorious morning in wild ramblings and in conversation. They dined
together, towards evening, at Emont Bridge, and then walked on to the
house of Captain Wordsworth, at Penrith. The family was absent, and the
poet had business which occupied him all the next day; so De Quincy took
a walk, sauntering along the road, about seventeen miles, to Keswick,
where he enquired for Greta Hall, the residence of the poet Southey. “It
stands out of the town a few hundred yards, upon a little eminence,
overhanging the river Greta.” Mrs. Coleridge and Southey came to the door
to welcome their visitor. “Southey was in person somewhat taller than
Wordsworth being about five feet eleven in height, or a trifle more, whilst
Wordsworth was about five feet ten; and partly from having slenderer
limbs, partly from being more symmetrically formed about the shoulders,
than Wordsworth, he struck me as a better and lighter figure, to the effect of
which his dress contributed; for he wore, pretty constantly, a short jacket
and pantaloons, and had much the air of a Tyrolese mountaineer.... His hair
was black, and yet his complexion was fair; his eyes, I believe, hazel, and
large, but I will not vouch for that fact; his nose aquiline; and he had a
remarkable habit of looking up into the air, as if looking at abstraction. The
expression of his face was that of a very acute, and an aspiring man. So far
it was even noble, as it conveyed a feeling of serene and gentle pride,
habitually familiar with elevating subjects of contemplation. And yet it was
impossible that this pride could have been offensive to anybody, chastened
as it was by the most unaffected modesty; and this modesty made evident
and prominent, by the constant expression of reverence for the great men of
the age (when he happened to esteem them such), and for all the great
patriarchs of our literature. The point in which Southey, however, failed
most in conciliating regard was, in all which related to the external
expression of friendliness. No man could be more sincerely hospitable, no
man more completely disposed to give up, even his time (the possession
which he most valued), to the service of his friends; but, there was an air of
reserve and distance about him—the reserve of a lofty, self-respecting mind,
but, perhaps, a little too freezing,—in his treatment of all persons who were
not amongst the corps of his ancient fireside friends. Still, even towards the
veriest strangers, it is but justice to notice his extreme courtesy, in
sacrificing his literary employments for the day, whatever they might be, to
the duty (for such he made it,) of doing the honors of the lake, and the
adjacent mountains.”
De Quincy says that the habits of the poet Southey were exceedingly
regular, and that all his literary business was conducted upon a systematic
plan. He had his task before breakfast, which, however, must have been an
inconsiderable nothing, for it occupied him only an hour, and rarely that, for
he never rose until eight, and always breakfasted at nine o’clock. He went
to bed precisely at half-past ten, and no sleep short of nine hours, refreshed
him, and enabled him to do his work. He usually dined between five and
six, and his chief labour was done between breakfast and dinner. If he had
visitors, he would sit over his wine, and talk; if not, he retired to his library,
until eight, when he was summoned to tea. At ten he read the London
papers; “and it was perfectly astonishing,” says De Quincy, “to men of less
methodical habits, to find how much he got through of elaborate business,
by his unvarying system of arrangement in the distribution of his time.” All
his letters were answered on the same day that they arrived. Even his poetry
was written by forced efforts, or rather, perhaps, by what De Quincy calls,
“a predetermined rule.” It was by writing prose, however, that Southey got
his living—made “his pot boil,” as he says; and his chief source of regular
income was derived from “The Quarterly Review.” At one time, however,
he received £400 a year for writing the historical part of “The Edinburgh
Annual Register.” This, however, he gave up, because the publisher
proposed to dock £100 from the salary which he had previously paid him.—
Southey, however, could afford to lose this large income, because he had an
annuity which had been settled upon him by his friend, Charles Wynne,
“the brother of Sir Watkin, the great autocrat of Wales.” This annuity,
however, when his friend married, Southey voluntarily gave up; and the
Granvilles, to whom Wynne was related by his marriage, placed Southey on
the civil list, for the sacrifice which he thus made.
Such, then, were the circumstances of Southey at the time of De
Quincy’s visit, and it must be owned that they were very comfortable, for a
poet. Wordsworth came on the day after De Quincy’s arrival, and it was
evident that the two poets were not on the most friendly terms; not that
there was any outward sign of this,—on the contrary, there were all the
exteriors of hospitality and good feeling on both sides; but De Quincy saw
that the spiritual link between them was not complete, but broken; that,
indeed, they did not understand, or fully sympathise with each other. Their
minds and habits were different—I had almost said totally different.
Wordsworth lived on the mountain top, composed there, and drew his
inspiration direct from Nature; Southey lived in his magnificent library, and
was inspired more by books than by natural objects.—Wordsworth’s library
consisted of two or three hundred volumes, mostly torn and dilapidated;
many were odd volumes; they were ill bound—not bound—or put in
boards. Leaves were often wanting, and their place supplied occasionally by
manuscript. These books “occupied a little homely book-case, fixed into
one of two hollow recesses, formed on each side of the fireplace by the
projection of the chimney into the little solitary room up stairs, which he
had already described as his ‘half kitchen, half parlour.’.... Southey’s
collection occupied a separate room—the largest, and every way the most
agreeable in the house.”
Wordsworth’s poetry was subjective—referred chiefly to the inner life of
man; and his dealings with Nature had a special reference to this inner life,
his imagery being the mere vehicle of his thought. Southey’s poetry, on the
contrary, was essentially objective,—a reflex of the outward nature,
heightened by the fiery colouring of his imagination. Wordsworth had a
contempt for books, or, at all events, for most books,—whilst Southey’s
library, as De Quincy says, was his estate. Wordsworth would toss books
about like tennis balls; and to let him into your library, quoth Southey, “is
like letting a bear into a tulip-garden.” De Quincy relates, that Wordsworth
being one morning at breakfast with him at Grasmere, took a handsome
volume of Burke’s from his book-case, and began very leisurely to cut the
leaves with a knife smeared all over with butter. Now tastes and habits such
as those which marked the two poets could not unite them very closely
together; at all events, not at this time; although they were subsequently,
and in later years, upon terms of close intimacy and friendship. Upon the
present occasion, however,—that is to say, during De Quincy’s visit to
Southey—the two poets managed very well together, and the evening was
passed agreeably enough. Next morning they discussed politics, and to the
horror of De Quincy, who was then a young man, and took no interest in the
passing movements of nations, and had always heard the French
Revolution, and its barbaric excesses, stigmatised as infernal,—who was,
moreover a loyal person according to the tradition of his fathers, and a lover
of Mr. Pitt—to his horror, the two poets uttered the most disloyal
sentiments, denouncing all monarchial forms of government, and proposed
to send the royal family to Botany Bay! This proposal, which Southey
immediately threw into extempore verse, was so comical, that the whole
party laughed outright, and outrageously; they then set off towards
Grasmere.
De Quincy speaks in the highest terms of Southey, and in the comparison
which he institutes between Southey and Wordsworth, the latter certainly
sustains loss. I refer the reader to the “Lake Reminiscences” for this, and
other most interesting particulars relating to these poets. Still I cannot bid
adieu to these “Reminiscences,” without using them once more, as
materials for an account of Greta Hall and its occupants.

You might also like